New Health Enhancement Program
Effective October 1, 2011, the state will implement the voluntary Health Enhancement Program (Program).
The Program has several important benefits. First, it will help you and your family work with the medical
providers that you choose from the existing state provider network to get and stay healthy. Second, it will save
you money on your healthcare. Third, it will save money for the state by focusing our healthcare dollars on
prevention. It’s your choice whether or not to participate, but there are many advantages to doing so.
You Save Money by Participating!
When you and all of your enrolled family members participate in the Health Enhancement Program, you will
pay lower monthly premiums and have no deductible for in-network care for the plan year. If one of you has
one of the five chronic conditions identified below, you will also receive a $100 cash payment, providing you
and all enrolled family members comply with Program requirements.
Requirements for Everyone Enrolled in the Health Enhancement Program
When you enroll in the Health Enhancement Program, you and your enrolled family members will need to get
age-appropriate wellness exams and immunizations, early diagnosis screenings (such as colorectal cancer
screenings, Pap tests, mammograms, and vision exams). Those enrolled in the dental plan must also get
annual dental cleanings. All of the plans cover up to two cleanings per year. Annual dental cleanings and
unlimited periodontal care are included in the Health Enhancement Program.
These particular conditions are targeted because they account for a large part of our total healthcare costs and
have been shown to respond particularly well to disease education and counseling programs. By participating
in these programs, affected employees and family members will be given additional resources to improve their
health.
These exams and screenings are designed to provide early diagnosis and appropriate education to employees
and their enrolled family members to help them stay healthy, and, if ill, to treat their illness. For those enrolled
in FLES, if one of the two employees chooses to enroll in HEP, then both parties must enroll.
Any enrolled member diagnosed with one of the five (5) chronic conditions outlined below must take part in an
educational and counseling program. Those conditions are as follows:
1. Diabetes
2. Chronic Obstructive Pulmonary Disorder or Asthma
3. Hypertension
4. Hyperlipidemia (high cholesterol)
5. Coronary Artery Disease (heart disease/heart failure).
This education and counseling programs consist of the following:
• Phone contact from a health care counselor from their medical insurance carrier;
• Receiving materials to help the individual to better understand and control or eliminate the disease
condition;
• Being provided with a variety of on-line and/or printed support tools and materials to further assist
them.
Individuals with one of these five conditions will not have a co-pay for office visits related to
their chronic condition.
The pay is the same regardless of the employee’s class coverage or the number of enrolled dependents with a
chronic condition.
Required Screenings
While the State Employee Health Plan will continue to cover an extensive schedule of periodic physical
wellness examinations and screenings, participants in the Health Enhancement program agree to comply with
the following minimum schedule of physical wellness exams and the following specific schedule of screenings
in order to be compliant with the Program:
• Scheduled Preventive Physical Examinations
• Well Child Visits:
o Birth to 1 6 exams (lmonth, 2 months, 4 months, 6 months, 9 months, 12 months)
o Ages 1-5 one per year
o Ages 6 -17 once every year
• Adult Wellness Physical Examinations:
o Ages 18- 39 every three years
o Ages 40- 49 every two years
o Ages 50 + every year
• Preventive Screenings
o Cholesterol screenings every five years from ages 20-29(typically done through a blood test in
conjunction with the schedule of wellness physicals above.) every two years from Ages 40-50;
every year from Ages 50 +
o Clinical breast examination for women by their health care provider every three years;
mammograms as recommended by your physician; one screening mammogram for every
female member who is between age 35 and 39.
o Cervical cancer screening every three years commencing at age 21
o Colorectal screenings beginning at age 50 consisting of screening options as decided by your
physician which options include colonoscopy every ten years; CT colonoscopy which may be an
appropriate alternative to a colonoscopy; or annual fecal occult blood test.
o Vision examination: every two years
o Dental cleanings: two cleanings per year for participants. Participants not enrolled in dental
coverage through the State Health Plan do not have to meet this screening requirement.
As to all of the above listed and described screenings, no employee or enrolled dependent shall be required to
get a listed and described screening which is against the recommendation of a physician or other health care
professional.
Participants who choose not to adhere to the requirements of the Health Enhancement program
will be given appropriate notice and opportunity to improve. The financial incentives for participation in the
health enhancement program shall be removed from members who themselves or whose covered dependents
fail to comply with the requirements of the program. They may return to the Health Enhancement Program
only upon coming into compliance and no sooner than the first day of the month following their demonstration
of compliance. Removal from the program shall not, in any case, be based upon the decision of any patient as
to the treatment they receive, or on the progress or lack of progress in the treatment of their illness. It shall
not be based on any other factor whatsoever except for the refusal of the patient to get required tests and
screening, and if applicable, to participate in one of the five (5) listed disease counseling and education
programs. Any removal shall be only upon prior notice to and the review by the Health Care Cost Containment
Committee.
Additional Benefit Plan Changes
The following changes affect your healthcare benefits whether or not you participate in the Health
Enhancement Program:
100% Coverage for Recommended Preventive Care
In-network well child visits and immunizations are already covered by the plan with no co-pay. As a result of
the Affordable Care Act, preventive care for adults is now 100% covered with no co-pay as well, when you use
in-network providers. This applies to all preventive services covered under the Affordable Care Act. For a list,
visit www.healthcare.gov/law/about/provisions/services/lists.html.
Pre-Certification Requirement
Making sure you get the right care – not too little and not too much – is one of the ways we can make the
best use of our healthcare dollars. Pre-certification is required before you have a diagnostic imaging procedure
such as an MRI, CT, CAT, or PET scan. If you use an in-network provider, your provider will take care of this
for you. If you use an out-of-network provider, you are responsible for getting pre-certification.
Emergency Room
Effective October 1, 2011, you will pay a $35 co-pay for emergency room visits, unless you are admitted to the
hospital from the emergency room or there was no reasonable medical alternative. Co-pays for use of urgent
care and walk-in clinics will be the same as your plan’s office visit co-pay.
Prescription Drug Changes
The Governor and SEBAC (State Employee Bargaining Agent Coalition) have reached an agreement that
establishes a Maintenance Drug Network Program, effective Oct. 1, that provides two options for state
employees and retirees under age 65 to obtain their maintenance drugs for certain chronic conditions:
o Obtain maintenance drugs through mail order; or
o Pick up maintenance drugs in person at any local pharmacy that is participating in the Maintenance
Drug Network.
To date, the following pharmacies are participating in the Maintenance Drug Network Program: all Big Y, CVS,
Price Chopper, ShopRite and Stop & Shop pharmacies, as well as Bordornaro's Pharmacy in Portland, and
Hope Street Pharmacy in Stamford. This means that instead of receiving these drugs through the mail, you
may pick up your prescriptions for maintenance drugs at any of these pharmacies.
Your prescription drug coverage is through Caremark. Prescription benefits are the same no matter which
medical plan you choose. The plan has a 3-tier co-pay structure which means the amount you pay depends on
whether your prescription is for a generic drug, a brand-name drug listed on Caremark’s preferred drug
list (the formulary), or a non-preferred brand-name drug.
If you or your family takes a maintenance medication, you will be able to get your first fill of that medication
at any participating pharmacy. After that your two choices are:
• Receive your medication through the Caremark mail-order pharmacy, or
• Fill your medication at a pharmacy that participates in the state’s new Maintenance Drug Network
Prescription drug co -pays are as follows Effective October 1, 2011:
For…
Maintenance Drugs
Non-Maintenance Drugs
90-Day Supply
30-Day Supply
Tier 1: Generic drug
$5
$5
Tier 2: Preferred
brand-name drug
Tier 3: Non-preferred
$10
$20
$25 ($10 if your physician certifies
the non-preferred brand-name
drug is medically necessary)
$35 ($20 if your physician certifies
the non-preferred brand-name
drug is medically necessary)
For those enrolled in the Health Enhancement Program, medications used to treat chronic conditions covered
by the Program’s disease education and counseling programs cost even less:
• $0 co-pay for Tier 1 (generic)
• $5 co-pay for Tier 2 (preferred)
• $12.50 co-pay for Tier 3 (non-preferred).
 There is zero co-pay for medications used to treat diabetes (Type 1 and Type 2).
To check which co-pay amount applies to your prescriptions, visit www.Caremark.com for the most up-to-date
information. Once you register, click on “Look up Co-pay and Formulary Status.” Simply type the name of the
drug you want to look up and you will see the cost and co-pay amounts for that drug as well as alternatives.
Preferred and Non-Preferred Brand-Name Drugs Which tier a drug is placed in is determined by Caremark.
Caremark’s Pharmacy and Therapeutics Committee reviews tier placement each quarter. If new generics have
become available, new clinical studies have been released, new brand-name drugs have become available,
etc., the Pharmacy and Therapeutics Committee may change the tier placement of a drug. If your doctor
believes a non-preferred brand-name drug is medically necessary for you, they will need to complete the
Coverage Exception Request form (available at www.osc.ct.gov) and fax it to Caremark. If approved, you will
pay the preferred brand co-pay amount.
If You Choose a Brand-Name When a Generic Is Available Prescriptions will be automatically filled with a
generic drug if one is available, unless your doctor completes Caremark’s Coverage Exception Request form
and it is approved. (It is not enough for your doctor to note “dispense as written” on your prescription; a
separate form is required.) if you choose a brand-name drug over a generic alternative and it is not approved
as medically necessary, you will pay the generic drug co-pay PLUS the difference in cost between the brand
and generic drug. If you have questions about your prescription drug benefits, contact Caremark at 1-800318-2572.
Below are some frequently asked questions about the Maintenance Drug
Network Program
Question: What is a "maintenance drug?"
Answer: Maintenance medications are those used to treat chronic conditions and are typically taken on a
regular basis. If you are currently getting a 90-day supply of a medication for a chronic condition at your
pharmacy, it is likely a maintenance drug.
Question: How do I know if my medication is considered a "maintenance drug?"
Answer: Caremark, the state's pharmacy benefits manager, maintains a list of those drugs frequently used by
state plan members that are considered maintenance medications.
Question: What do I need to do after Oct. 1 to comply with the maintenance drug program?
Answer: After Oct. 1 you can fill your prescription as you always have, in person, at your local pharmacy. If
your prescription is for a maintenance drug you will only receive a 30-day supply. Following that prescription
fill, Caremark will notify you directly by mail that your next refill for that medication must be refilled through
the maintenance program. Caremark will also inform you of your options, which include filling it at a local
pharmacy in the Maintenance Drug Network or using Caremark's mail order process. If you wish to register for
the mail order process by phone, you may call 1-800-875-0867 or you can log on to
www.caremark.com/faststart and sign in to register. Have your prescription card number, the names of your
medicines, your doctor's information and your payment information (credit card, debit card, check) ready for
your co-pay.
Question: Which local pharmacies have joined the Maintenance Drug Network?
Answer: To date, all Big Y, CVS, Price Chopper, ShopRite and Stop & Shop pharmacies have agreed to
participate. In addition, Bordornaro's Pharmacy in Portland, Hope Street Pharmacy in Stamford have agreed to
participate. We will post details as additional pharmacies may join the network in the coming weeks.
Question: What if I need a prescription that is NOT a maintenance drug?
Answer: If your prescription is not a maintenance drug, then you can fill it - in person - at your pharmacy of
choice as you always have.
Question: For security and privacy reasons, I would rather not receive my maintenance drug(s) by mail. Is
there an alternative for me?
Answer: If you would prefer to pick up your maintenance medications in person, use one of the local
pharmacies identified above that are participating in the Maintenance Drug Network. Caremark has offered
every pharmacy in the state the ability to participate in this network. If you fill your prescription at these
locations you will be able to get a 90-day fill for one co-pay.
Question: How do I know whether my pharmacy is participating in the Maintenance Drug Network?
Answer: The list of pharmacies participating in the Maintenance Drug Network will be updated regularly and
is available on the comptroller's website http://www.osc.ct.gov/empret/healthin/2011hcplan/index.html
Question: If my prescription drug requires refrigeration or other special care, can it be delivered through mail
order?
Answer: Drugs that require refrigeration will be delivered in a specialized package to maintain the necessary
temperature. You may also wish to pick up these medications at one of the local pharmacies participating in
the Maintenance Drug Network.
Question: If I elect to receive my drugs through the mail, rather than pick them up at a Maintenance Drug
Network pharmacy, how will I be billed and pay for the co-pay?
Answer: You will be billed for your co-pay, and can pay by credit card, debit card or check.
Question: If I participate in the maintenance drug program and have a question about my prescription, who
do I turn to for questions about my medication?
Answer: Call the pharmacy where you filled the prescription. If you used Caremark’s mail order service, you
can call Customer Service at 1-800-318-2572.
Question: I am a retiree. Am I required to participate in the maintenance drug program?
Answer: The program is only required for current retirees under the age of 65. If you are a current retiree
over the age of 65, you are not required to participate.
Question: If my spouse is covered under my insurance and uses CVS for a maintenance drug while I
continue to use Walgreens for medications as needed, will we receive separate cards from each provider?
Answer: No – the prescription provider (CAREMARK) is the same.
GENERAL FAQ’s
Question: Will everyone get new cards?
Answer:
Anthem:
New ID cards will be sent to active employees.
Oxford:
New ID cards will be issued to all active employees.
Caremark:
No new ID cards for anyone other than a new employee/dependent on the plan.
United Dental:
CIGNA Dental:
Only members making a change to their dental coverage will get a new card.
No new ID cards for anyone other than a new employee/dependent on the plan.
Question: Who will track compliance?
Answer: The health insurance carriers: Anthem, Oxford, Cigna and UnitedHealthcare.
Question:How is compliance tracked?
Answer: Through claims data. No information related to an individual’s health status or condition will be
provided to the State of Connecticut.
Question: What if an employee has already completed a screening prior to October 1, 2011?
Answer: The health insurance carriers will be able do a look back at claims on record.
Question: Will employees be reminded of what they need to do?
Answer: Once per year a reminder notice will be sent out to employees that enrolled in HEP that haven’t
completed their required screenings and exams.
Question: What if they’re reminded to do a screening they’ve already completed?
Answer: They would need to contact their health insurance carrier to “self-report” the screening. A method
for “self-reporting” is currently being developed.
Question: What if, after being reminded, an employee and/or one of their enrolled dependents still do not
schedule their required screenings?
Answer: They will be deemed noncompliant. They will be removed from HEP for the following benefit year
and will have to pay the $100 monthly STPLAN deduction and $350 in-network deductible for each enrolled
dependent.
Question: What if an employee wants to opt-out of the program?
Answer: They will have the option to opt-out during Open Enrollment each year. They will then be
responsible for the $100 monthly STPLAN deduction and $350 in-network deductible for each enrolled
dependent.
Question: By joining the Health Enhancement Program, will my family and I have access to the same network
of doctors and healthcare practitioners?
Answer: Yes, the network of participating providers is the same whether or not you participate in the Health
Enhancement Program.
Question: If I participate in the Program, will the State have access to my private healthcare information?
Answer: No. All claim and diagnosis data is kept strictly confidential, and will only be reviewed by the health
insurance carrier to ensure you follow the Program requirements.
Question: If I don’t follow the Program requirements, what will happen?
Answer: If you do not get required tests or screenings, or participate in the disease counseling and
education program for your chronic condition, if applicable, you will be given appropriate notice and
opportunity to meet Health Enhancement Program requirements. You may be removed from the Program and
required to pay an increased premium and an in-network deductible for the next year.
Question: If I participate in the disease education and counseling program for me but my health condition
gets worse, will I be removed from the Program?
Answer: Not at all! The program is designed to enhance the patient’s ability to work with their doctors to
make the most informed decisions about staying healthy, and, if ill, to treat their illness. The purpose of the
disease education and counseling program is to encourage healthy behaviors, and whether or not your
condition actually improves or gets worse will not affect your eligibility to continue participating and receiving
the financial discounts.
Question: When does the HEP begin? Does it run for the calendar year or for the plan year?
Answer: For this year only, HEP will run from October 1, 2011 through June 30, 2012. For subsequent
years, it will coincide with the plan year (7/1/XXXX – 6/30/XXXX)
Rev. 10/20/11 HR